Why ACOs Must Build Trust with Providers and Patients to Meet Goals

As ACOs develop approaches to Value-Based Health Care, they are struggling with a key issue: lack of trust. How can providers commit to collective cost reductions that could have potentially negative revenue consequences for themselves individually or on their practices? If they don’t believe that the other players or their ACO are operating in the best interests of all involved, how can they participate in the ACO’s goals? Conversely, how can the ACO create effective leadership and collaboration if physicians are unwilling to commit to making the model succeed?

Likewise, ACOs have to work harder to earn patients’ trust. Ask any ACO for their top issues and they’re certain to mention the volume of out-of-ACO services. If consumers do not trust the ACO or its providers, they will not be loyal patients or necessarily follow provider-recommended treatment plans. Successful engagement requires trust.

Trust is built through internal branding between physicians and ACO leadership and payers, and through external branding with consumers and referral partners. This article was written by someone who neither understands ACOs or branding, and merely scratches the surface and only talks AT the subject of trust. A disappointment. Could have been an excellent topical blog post.

Value-based purchasing is a problematic phrase when used in the context of ACOs, trust and loyalty.

First, the appointed leadership of the ACO must create and nurture a “culture” of accountability. Only then will accountability for cost and quality organically arise without policing. One way to do this is to build internal practice guildeines and protocols, rather than try to force a “book” of guidelines and EBM protocols on a group of physicians in a community. If the physicians feel they were marginalized in developing the ACO’s unique guidelines and protocols, the ACO will always struggle with buy in, accountability, and always need a shepherd to herd the cats. It doesn’t need to be so difficult. Physicians should see and realize the value proposition and their role in Value-based care. As shareholders and members, the first value to establish is theirs. If the “values” themselves don’t feel natural or resonate with each one, they cannot “live” the value, mission, mantra, and culture. Branding affords them this natural and organic approach. To skip brand building and skip the development of internal brand values from within the group is to always struggle with pulling the team together. The team working together is what creates the value in value-based care for both payers and consumers.

From this branding exercise comes the identification of the groups “ideal customer”. Once the ideal customer has been identified as a segment in the market place, not all payers (nor all consumers) will be categorized as “ideal” customers who will resonate with the “product” produced by the ACO members. Identifying the ideal customers of the ACO is accomplished by creating ideal buyer and patient personas. This leads to market segmentation. Who is a preferred payer? Who is the preferred patient? Who should buy someplace else? From someone else? How are these persona traits communicated to the physician stakeholeders? Through brand creation and explanation of ACO brand values. Creating the personas of ideal patients and ideal payers informs the ACO what the ideal criteria for cost and patient care performace should be. It comes from the knowledge of who is the customer, and the identification of what they need and want. The ACO cannot be all things to all patients or all payers. Ideal customers also include internal customers of the ACO (employees, leadership and community physicians.) Not all physicians or employee applicants will be a “fit” in the ACO.

If one of the values instilled in the ACO is collaboration, and the guidelines are developed from within (even if adapted around Milliman or some other reference standard of protocols and payer accepted or preferred guidelines), there should be no need for a punitive process. Construct a hierarchy for peer review within each specialty. Operate it in a similar style as M&M and come from an orientation of education and collegial respect. Your ACO will be easier and more gratifying to operate and sustain. Make perceived and proven problems the topics of inservices and grand rounds as part of a continuous quality improvement program. Offer CME for both the presenter and the membership to boost value even further. Give way to a culture of respectful critical thinking and Q&A. Allow everyone to feel safe to ask “why” something is recommended in order to grow organic concensus.

Before attempting to measure and compare “costs”, define by concensus what will be a defined episodes of care. One cannot fairly and accurately measure costs or reduce them if the window of observation for an episode of care is not standardized. Each window must be as long as it takes for treatments and interventions to prove they worked or didn’t work. This is the first step toward precision medicine, which is where the value lies in healthcare. Precision intervention reduces costs over time and raises outcomes, but may cost a little more in the beginning. The transition takes patience, documentation, measurement, analysis and interpretation; not withholds and capitation reimbursement schemes. Once the episodes of care have been developed and established and accepted, only then can price transparency and estimation be more accurate and practicable.

In order to build and discuss distribution formulas for incentives/rewards and risk paybacksthe preliminary work to design the ACO’s unique guidelines, protocols and roles and responsibilites of each primary care and specialist member are necessary. If you don’t do this in the right order, you will never get to the level where distributing the berries in the pie feels equitable.

The author(s) suggest “Create central support for value-based medical decisions for key procedures, chronic illnesses, cancer care and health screenings, so that physicians and their patients have research data and appropriate criteria for reviewing key treatments, costs, benefits and risks.” but give no recommendation for how to go about this. What kind of support? Database, portal, specialty leadership, mentorship, elected “go-to” authorities?

Validated quality of care and outcome information should be integrated into ACO marketing, advertising and public relations. Media should be notified by professional public relations specialists when breakthrough treatments, quality outomes and cost savings to build brand recognition, value, and reputation.